Is balloon dilation of the Eustachian tube (code 69706) medically necessary for a 46-year-old male with deviated nasal septum, hypertrophy of nasal turbinates, and Eustachian tube dysfunction?

Medical Necessity Assessment for Balloon Dilation of Eustachian Tube (CPT 69706)

Primary Recommendation

Based on the available documentation, balloon dilation of the Eustachian tube (CPT 69706) CANNOT be approved at this time due to insufficient documentation of required criteria, specifically the absence of tympanogram results and incomplete evaluation of contraindications.

Critical Missing Documentation

The clinical policy board (CPB) criteria for balloon dilation of the Eustachian tube in adults requires ALL of the following, which are NOT adequately documented:

• Tympanogram type B or C is REQUIRED - The documentation states "NOT SURE" for this criterion, meaning no tympanogram results are available or documented 1
• Exclusion of contraindications is INCOMPLETE - The documentation indicates "NOT SURE" for multiple contraindications including carotid abnormalities, nasopharyngeal/skull base neoplasm, patulous Eustachian tube, and untreated allergic rhinitis/rhinosinusitis/laryngopharyngeal reflux 1

Clinical Context and Eustachian Tube Dysfunction

While the patient does have documented symptoms suggestive of Eustachian tube dysfunction:

• Left ear swelling with sensation of fullness and need to "pop" 1
• Hearing at approximately 80% in left ear 1
• Fluid discharge from ear requiring multiple cleanings at night 1
• Physical examination findings of left ear swelling with probable Eustachian tube dysfunction 1

However, symptoms alone are insufficient without objective tympanometry confirmation.

Relationship Between Nasal Pathology and Eustachian Tube Dysfunction

The patient's nasal pathology may contribute to Eustachian tube dysfunction:

• Inferior turbinate hypertrophy is associated with Eustachian tube dysfunction, and radiofrequency turbinate reduction has been shown to improve ETD in 19.59% of cases with grossly impaired function 2
• The planned septoplasty and turbinate reduction may secondarily improve Eustachian tube function without requiring balloon dilation 2

Approved Procedures

The septoplasty (CPT 30520) and turbinate reduction (CPT 30140) ARE medically necessary and should be approved based on:

• Documented septal deviation with right-sided bony spur causing continuous nasal airway obstruction 1, 3
• Bilateral turbinate hypertrophy confirmed on examination 1
• Failed medical management with Flonase (intranasal corticosteroid) 1
• Significant symptoms affecting quality of life including inability to breathe through right nostril 1
• The American Academy of Allergy, Asthma, and Immunology recommends septoplasty when septal deviation causes continuous nasal airway obstruction not responding to 4+ weeks of appropriate medical therapy 1

Required Documentation for Future Consideration of CPT 69706

If Eustachian tube dysfunction persists after septoplasty and turbinate reduction, the following must be documented:

• Tympanogram showing type B or C pattern (objective evidence of ETD) 1
• CT imaging of skull base to exclude carotid abnormalities 1
• Nasopharyngoscopy to exclude nasopharyngeal or skull base neoplasm 1
• Confirmation that Eustachian tube is NOT patulous (paradoxically open) 1
• Documentation that allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux have been adequately treated 1
• Persistent symptoms after addressing nasal obstruction with septoplasty/turbinate reduction 2

Clinical Pitfalls to Avoid

• Do not assume clinical symptoms of ETD are sufficient without tympanometry - objective testing is mandatory per policy 1
• Do not proceed with balloon dilation before addressing the nasal obstruction, as turbinate reduction alone may resolve ETD in a significant percentage of patients 2
• The CT soft tissue neck already performed shows no acute abnormalities, but specific skull base protocol imaging may be needed to exclude vascular contraindications 1

Recommended Action Plan

1. Approve septoplasty (30520) and turbinate reduction (30140) - criteria clearly met 1, 3
2. Deny balloon dilation (69706) - insufficient documentation of required criteria 1
3. Request tympanometry and complete contraindication evaluation if ETD symptoms persist 3-6 months post-septoplasty 1, 2
4. Re-evaluate for balloon dilation only after nasal surgery recovery and with complete objective documentation 1, 2